Axis Internationalism: Spanish Health Experts and the Nazi ‘New Europe’, 1939–1945

Abstract

Many of the forms and practices of interwar internationalism were recreated under the auspices of the Nazi ‘New Europe’. This article will examine these forms of ‘Axis internationalism’ by looking at Spanish health experts' involvement with Nazi Germany during the Second World War. Despite the ambiguous relationship between the Franco regime and the Axis powers, a wide range of Spanish health experts formed close ties with colleagues from Nazi Germany and across Axis and occupied Europe. Many of those involved were relatively conservative figures who also worked with liberal international health organisations in the pre- and post-war eras. Despite their political differences, their opposing attitudes towards eugenics and the tensions caused by German hegemony, Spanish experts were able to rationalise their involvement with Nazi Germany as a mutually-beneficial continuation of pre-war international health cooperation amongst countries united by a shared commitment to modern, ‘totalitarian’ forms of public health. Despite the hostility of Nazi Germany and its European collaborators to both liberal and left-wing forms of internationalism, this phenomenon suggests that the ‘New Europe’ deserves to be studied as part of the wider history of internationalism in general and of international health in particular.

In November 1941 over fifty government officials and public health experts representing twenty different states attended an international tuberculosis conference in Berlin. In response to the sharp increase in tuberculosis cases across Europe since 1939, they agreed to form the new International Association against Tuberculosis which would lead the Europe-wide fight against the disease during the war and help lay the foundations for a better post-war future.¹ On the surface this conference looked like a straightforward example of the type of international medical cooperation that had become increasingly common since the mid-nineteenth century with the internationalisation of medicine and public health.² Indeed many of the delegates had been involved with pre-war international health organisations such as the International Union Against Tuberculosis and the League of Nations Health Organisation (LNHO), and would go on in the post-war era to work with the WHO and UNICEF. The difference, of course, is the context within which the conference occurred. Organised at the invitation of the Reich Health Office, it encompassed only Axis, occupied or neutral states, and took place within the midst of a European public health crisis provoked by the Nazi war effort and occupation, characterised by the deliberate starvation of millions of Soviet prisoners of war, as well as the restriction of food, fuel and medical supplies across the occupied territories and the unchecked spread of disease in Jewish ghettos.³

The conference was part of a much wider pattern of wartime health cooperation and exchange between medical professionals and public health officials across Axis, Axis-aligned and neutral states, which reached its peak in late 1941 and 1942 before being steadily undermined by German military defeats. Health, in turn, formed only a small part of the wide range of international organisations and meetings convened under the umbrella of the Nazi ‘New Europe’, which brought together student and women's groups, as well as artists, writers, journalists, scientists, doctors and social policy experts.⁴ As with the case of the 1941 tuberculosis conference, many of these events consciously echoed the language and practices of interwar internationalism. This ‘Axis internationalism’ seems profoundly out of place in the context of Nazi rule in wartime Europe and the anti-internationalist ideology which underpinned it. The principles of interwar internationalism were based on the formal equality of sovereign states (at least for the ‘civilised’ nations of Europe and the Americas), mutually-guaranteed territorial integrity for all states both large and small and the promise of democratically-led social progress through international cooperation.⁵ Nazi geopolitics, to the extent it can be clearly defined, fundamentally rejected these principles and the world-view which underpinned them, projecting in their place theories of world order based on racial struggle between nations, international hierarchies and regional hegemony.⁶ When these ideas were put into practice across occupied Europe after 1939, the result was a racially-based hierarchy of European states geared towards maintaining the German war effort via a system of plunder, coercion and exploitation and expanding German Lebensraum through the destruction or subjugation of the sovereign states of Eastern Europe and their Slavic and Jewish inhabitants.⁷

How do we explain the existence of ‘Axis Internationalism’ within this context? The events and initiatives it encompassed formed part of the more benign vision of German hegemony propagated through the idea of the ‘New Europe’. Although there were some within the Nazi regime who embraced this vision, particularly within the economics and foreign ministries, the principles which lay behind it were never taken seriously by Hitler or the regime's senior leadership.⁸ Historians have tended to examine the ‘New Europe’ primarily as a German propaganda strategy which appealed to a minority of pro-Nazi collaborators across occupied Europe, for whom it represented a continuation of the forms of international fascism which had begun to develop in the 1920s and 1930s.⁹ From this perspective, the new forms of international health that emerged in Nazi-dominated Europe appear as little more than empty propaganda exercises aimed at Europe's fascists and Nazi fellow-travellers. This view is reflected in the absence of ‘Axis internationalism’ from much of the existing literature on internationalism and international health, which focusses primarily on liberal or left-wing international organisations and networks, and which tends to pass over the period of the Second World War, jumping more or less seamlessly from the demise of the League of Nations to the emergence of the post-war UN system.¹⁰

Whilst propaganda was clearly an important part of ‘Axis internationalism’, a more complex picture emerges when Nazi-led forms of international health are examined from the perspective of Franco's Spain. The Franco regime maintained close political, military and economic ties with the Third Reich, particularly during the first half of the war, dispatching the volunteer Blue Division to fight on the Eastern Front in 1941 and providing logistical support and vital supplies for the German war effort.¹¹ Building on relationships formed during the Spanish Civil War, Nazi officials enjoyed a good deal of influence within Spain itself, particularly in the fields of culture and propaganda.¹² At the same time, Spain was not occupied and never formally joined the Axis powers, while the Allies were able to exert a significant degree of pressure on the regime through economic blockades and via their numerous sympathisers amongst the armed forces and Spanish elites.¹³ Despite this ambiguous relationship with the Axis powers, Spanish health experts formed close and widespread ties with colleagues from Nazi Germany and across Axis and occupied Europe, sending the largest delegation to the 1941 tuberculosis conference in Berlin and taking part in numerous medical visits, tours and exchanges. As with much of the ‘New Europe’ historiography, most studies of Spain's relationship with the Third Reich have focused either on state-level diplomatic relations or on the politically-motivated collaboration of the Falange and a minority of pro-Nazi Spaniards.¹⁴ In the case of health and medicine however, the majority of Spanish health experts involved with Nazi Germany were military figures, monarchists and Catholics from the more conservative end of the Francoist political spectrum, and many had a history of working with liberal international health organisations such as the LNHO in the pre-war era. The participation of Spanish experts from across the Francoist political spectrum suggests that these new forms of ‘Axis internationalism’ were widely regarded, at least during the early years of the war, as the legitimate successor to the pre-war international system.

This article will explore the extent and appeal of ‘Axis internationalism’ from the perspective of Spanish experts, looking particularly at their relationship with Nazi Germany during the Second World War. It will examine the activities and individuals involved, the shared interests, language and ideals, both real and imagined, which underpinned them and the tensions and contradictions that existed within the relationship. The practical impact of international health cooperation within the ‘New Europe’ was relatively limited. Although some of Spain's wartime public health policies were influenced by Nazi Germany, many of the more ambitious plans that were drawn up for a new Nazi-led international health system in late 1941 and 1942 had no chance of being implemented before the string of defeats on the Eastern Front and the Allied invasion of Italy in 1943 had radically undermined the political credibility of the Axis cause. The willingness of Spanish experts to engage with Nazi Germany, however, illustrates the degree of support these forms of ‘Axis internationalism’ enjoyed across the European right during the early years of the war. The use of internationalist language and practices and the traditional prestige of German science and medicine appealed to conservative European elites, who were willing to overlook or rationalise away the political qualms they felt about the Nazi regime. The tensions that emerged stemmed more from the resentment felt towards overt German hegemony than from ideological or political differences between the individuals involved.

Spanish Experts in the ‘New Europe’

In October 1941 Spain's Director General of Health José Palanca, accompanied by Primitivo de la Quintana, the head of public health in Madrid, departed on a tour of the ‘New Europe’. Over the next two months the pair travelled to Berlin, Stuttgart, Munich, Vienna, Cracow, Warsaw, Lemberg, Milan and Rome. During the trip they visited sanatoria and troop hospitals, studied the nutritional situation in various countries, discussed the typhus epidemic sweeping through the territories of the General Government, attended the international tuberculosis conference in Berlin and met with the leaders of the Italian public health service in Rome.¹⁵ Although the two men belonged to the Catholic, monarchist and military traditions of Spain's conservative Department of Health and did not share the fervent pro-Nazi sympathies of some of their Falangist colleagues, their tour represented the peak of cooperation between the Spanish public health profession and the Third Reich.¹⁶ It also encompassed the two main areas around which this cooperation flourished: typhus and tuberculosis.

The fight against typhus lay at the heart of the extensive public health cooperation between Axis and Axis-aligned European states during the war, including scientific cooperation in the form of exchanges amongst researchers and international work on the development of vaccines. The disease had become endemic across Eastern and Central Europe since the start of the war, exacerbated by military mobilisation and civilian displacement, posing a major risk to both the German public health system and troops fighting on the Eastern Front. Spain was also suffering from a major typhus outbreak at the time, in part due to the regime's initial reluctance to recognise the problem in the immediate aftermath of the Civil War.¹⁷ Spanish experts were deeply involved in international wartime cooperation concerning typhus control. Typhus experts from German institutions including the Hamburg Institute of Tropical Medicine and the Frankfurt Institute for Experimental Therapy undertook study visits and lecture tours in Spain during the first half of the war, and German researchers worked on typhus in Seville and elsewhere. Spanish students were also invited to join international teams working on typhus vaccines at the military Institute for Virology in Cracow and the Behring Institute in Lemberg.¹⁸ There was a significant degree of cooperation between public health officials on the development of anti-typhus policies. Primitivo de la Quintana, for example, led the fight against typhus in Madrid between 1941 and 1942, and during his trip to Germany was not only able to study anti-typhus measures there and in the occupied territories but also gave a paper on the Spanish epidemic to the Reich Medial Association in Berlin in the presence of Reich Health Minister Leonardo Conti.¹⁹ In 1942 José Palanca cited the influence of his visit to Germany and the support of the Reich Medical Association in the development of Spanish anti-typhus programmes.²⁰

In the field of tuberculosis, cooperation between Francoist health experts and their German and Italian counterparts had begun shortly after the outbreak of the Spanish Civil War in 1936. Like many authoritarian states across Europe, Franco's government used the control of tuberculosis to promote its political competence and concern for social welfare, with the construction of sanatoria presented as a symbol of social progress and scientific modernity.²¹ Francoist authorities established the National Anti-Tuberculosis Council, under the leadership of José Palanca, just a few months after the outbreak of the Civil War in December 1936, and the provision of sanatoria beds appeared as a recurring theme in propaganda aimed at the foreign press.²² Nationalist public health experts were influenced by the tuberculosis control policies adopted by authoritarian European governments, with journals carrying frequent reports on developments in Italy, Germany and Hungary.²³ Fascist Italy had introduced a tuberculosis insurance scheme in 1927, which the Falange proposed to copy in Spain during the Civil War, and which loomed large in Spanish thinking on the construction of a modern social welfare system.²⁴ The relationship between the National Anti-Tuberculosis Council and its equivalents in Germany and Italy, the Reich Tuberculosis Committee and the Italian National Fascist Federation for the Fight Against Tuberculosis, formed the foundation of international cooperation during the Second World War, with the three organisations regularly sending experts to speak at each other's national conferences and organising tours, exchanges and research visits after 1939.²⁵

The result of these efforts, and the centrepiece of Palanca and Quintana's tour, was the international tuberculosis conference in Berlin. Spain's delegation included the Director of the National School of Public Health Gerardo Clavero Campo and leading figures from the National Antituberculosis Council. It had been organised by Leonardo Conti and President of the Reich Tuberculosis Committee, Otto Walter, with the stated goal of forging international cooperation at a time when the mass movement of people across Europe, particularly migrant workers, risked sparking the kind of tuberculosis epidemic seen during the First World War.²⁶ The new International Association Against Tuberculosis would disseminate experiences and ideas through a biannual ‘world conference’ and a multilingual international journal. Its proposed structure reflected political hierarchies within the ‘New Europe’. Germany and Italy were assigned the most senior roles, with the head of the Italian Anti-Tuberculosis Federation elected president, whilst more junior positions were granted to key allies such as Hungary and Spain. In reality, however, the association remained under German control, with its headquarters in Berlin and Otto Walter placed in charge of its administrative committee. Although the conference was primarily intended to begin preparations for post-war cooperation, the delegates began to draw up ambitious plans concerning the treatment of migrant workers, occupational therapy and the collection and dissemination of epidemiological statistics.²⁷

The language used at the conference reflected the extent to which Nazi authorities aimed to position themselves within the traditions of international health cooperation which had developed since the nineteenth century, and to present the proposed International Association against Tuberculosis as an improved version of the pre-war international health system. Otto Walter lamented that international efforts in the past had not always been easy or effective but argued that the war had bought the peoples of Europe into much closer contact than ever before, ushering in a new era of ‘intimate collaboration’.²⁸ The field of public health, he argued, was the perfect vehicle for strengthening international cooperation because ‘no state wishes to become better than the others in preserving the health of its own people.²⁹ The new association would represent an improved form of international health, more effective that the pre-war work of the International Union Against Tuberculosis in that it would go beyond sterile debates at conferences to foster regular, active exchange between experts in different countries and have a genuine impact on national systems.³⁰ Leonardo Conti dwelt on the need to find international solutions to an international problem, and argued that the success of this new form of international cooperation would rest on the ideological unity of the nations involved, ‘intimately connected peoples, who constitute a bloc with a common destiny’.³¹ The scientific mission of the conference presented analogies, he argued, with the political mission of the Anti-Comintern Pact meeting taking place in Berlin at the same time. Joint work in the field of tuberculosis would be the foundation stone for wider public health cooperation across Europe, helping not only to win the war but to help forge a better post-war world.³²

Nazi authorities adopted the language and practices of pre-war internationalism in a number of different fields during the early years of the Second World War. In some cases this involved the formation of new ‘international’ or ‘European’ bodies bringing together cultural, technical or professional groups, such as the organisations for European youth, women and writers set up between 1941 and 1942. In other cases it involved appropriating existing international organisations which had either fallen under direct German control or were of practical interest for Nazi authorities. In the field of health, for example, German officials attempted to transfer the International Office of Public Hygiene (Office International d'Hygiène Publique; OIHP) from Paris to Berlin or Vienna and to ‘Europeanise’ the Swiss-based International Hospital Federation.³³ In some instances Nazi authorities physically expropriated the sites of pre-war international institutions. When the International Labour Office (ILO) moved to Montreal in 1940, the German Labour Front attempted to occupy its former headquarters in Geneva and transform its Central Office for Joy and Labour into an alternative international labour organisation.³⁴ Beyond these rather superficial attempts to expropriate the trappings of pre-war internationalism, Nazi authorities also demonstrated a willingness to borrow ideas and practices from liberal international organisations when the occasion demanded. The wartime dispute between Hungary and Romania over Transylvania, for example, prompted Nazi authorities to adopt the language of international mediation and minority rights to diffuse a potentially damaging conflict between its Axis rivals, establishing a joint German-Italian Commission on the issue which echoed many of the goals and expectations of its precursors within the League of Nations.³⁵

Whilst many of these initiatives were aimed at establishing German hegemony over important technical bodies, the evidence from the international tuberculosis conference also suggests that they were remarkably successful in attracting support from experts who had worked with ‘mainstream’ international organisations prior to the war, or would go on to do so in the post-war era. This was particularly true in the case of Spain. José Palanca, for example, was a former Rockefeller Fellow who had been Spain's representative at the OIHP before the Civil War and would be Spain's lead delegate to the WHO from 1955.³⁶ Primitivo de la Quintana also worked with the WHO in the 1950s, whilst Gerardo Clavero Campo worked with both the WHO and UNICEF.³⁷ Like José Palanca, Clavero Campo was happy to maintain links with the Rockefeller Foundation, the LNHO and Nazi Germany throughout the Second World War, reflecting a professional enthusiasm for international health which appeared to transcend political boundaries.³⁸ Other delegates at the conference had a similar international pedigree. The Hungarian bacteriologist Jósef Tomcsik had worked with the Rockefeller Foundation in the interwar period.³⁹ The German social hygienist Wilhelm Hagen, officially representing the General Government at the conference, went on to work with the WHO after the war.⁴⁰ Both Niels Sjorslev from Denmark and Edouard Rist from France attended the first post-war meeting of the re-formed International Union Against Tuberculosis in 1950.⁴¹ The overlap of participants between liberal and Nazi-led organisations illustrates the success of Nazi authorities in presenting their wartime plans as a continuation of pre-war international health and the willingness of European expert to accept Nazi leadership during a period of global dislocation in which pre-war international networks had largely broken down.

The background of Spanish experts involved with Nazi Germany also emphasises the willingness of traditional, conservative elites to engage with Nazi-led international health during first half of the war. The Spanish experts with the clearest political motives for building close ties with the Third Reich were those linked to the Falange. Building on strong relationships formed during the Civil War, many Falangists enthusiastically embraced the idea of returning Spain to the heart of European political life within the Nazi New Order.⁴² The movement's more radical elements moved even closer to Nazi Germany following the government reshuffle of May 1941, which reduced their influence within the Franco regime, and Falangist leaders made numerous trips to the Third Reich.⁴³ Nazi authorities periodically returned to the idea of replacing Franco with a Falangist-dominated regime.⁴⁴ Health and medicine played a role within these wider political relationships, particularly in the case of the medical services of the Blue Division. The Division's hospitals and medical services provided an opportunity for Falangist soldiers, doctors and nurses to experience the Third Reich first hand and acted as spaces for wider contacts between Falangists and their Nazi counterparts. Blue Division veteran and National Delegate for the Falange's health organisation, Agustín Aznar, developed ties with Leonardo Conti and the Reich Medical Association, and was involved in the dispatch of Spanish doctors to work in the Reich.⁴⁵ Another leading Falangist, the journalist, psychiatrist and historian of medicine Pedro Laín Entralgo, also developed strong links with German authorities and was one of the most vocal advocates of the Axis cause during the early years of the war.⁴⁶

Rather than revolving around the Falange, however, the majority of health-related cooperation between Spain and the Third Reich during the war involved the Spanish Department of Health and the more conservative public health experts who belonged to it. The department formed part of the Interior Ministry (Ministerio de la Gobernación), led in 1941 by the monarchist Valentín Galarza, a prominent opponent of the Falange within the Franco regime. Over the course of the 1940s the department was involved in an on-going power struggle with the Falange over control of the Spanish health system.⁴⁷ It was dominated by military, Catholic and monarchist figures, representatives of the National Catholicism that lay at the heart of the early Franco regime.⁴⁸ These conservative elites, in contrast to their Falangist counterparts, were generally more ambivalent towards the Axis cause and traditionally much more hostile towards the idea of European unity and cooperation.⁴⁹ Of the Department's experts who cooperated most closely with Nazi Germany, José Palanca came from a family of military doctors and had served as a parliamentary deputy with the right-wing CEDA party under the Second Republic, whilst Primitivo de Quintana would join the monarchist opposition to Franco after the Second World War.⁵⁰ Nevertheless, these conservative experts proved just as willing to work with Nazi Germany as their Falangist counterparts, and in many instances the two groups were involved in the same networks and initiatives.

Ideology, Language and ‘Totalitarian’ Public Health

How do we explain the willingness of Spanish experts from across the Francoist political spectrum to cooperate so extensively with Nazi Germany, particularly given that Spain's ambiguous relationship with the Axis powers meant they were free from the direct pressures faced by their colleagues in occupied Europe? In the post-war era many of those most closely involved with the Third Reich came to emphasise the tensions and areas of disagreement in their relationship with Nazi Germany, presenting them as indicative of a fundamental incompatibility between Spanish principles, whether Falangist or conservative, and the Nazi regime. Primitivo de la Quintana, for example, had given enthusiastic reports to newspapers about his visit to Germany after his return in 1941,⁵¹ but following his death in 1996, Pedro Laín Entralgo (who had renounced his support for Nazi Germany and the Franco regime in the post-war period) claimed that Quintana's despair at what he witnessed in Nazi-occupied Europe had prompted him to break from the Franco regime and resign from the Department of Health.⁵² In his memoirs published in 1964, José Palanca presented his experiences of Nazi Germany in a similarly negative light. The tuberculosis conference he described as ‘a small farce’, with everyone present aware that Germany was going to lose the war and that plans for a new organisation weren't going to bear fruit.⁵³ As well as criticising the atheism of the Nazi regime, he also dwelt on the experience of Jews in the General Government territories, claiming he knew that the Nazis weren't interested in combatting the typhus epidemic in ghettos and recounting a story of an incident he witnessed in which the head of public health in Warsaw mistreated a Jewish doctor and threatened to send him to a concentration camp.⁵⁴

These sources, however, need to be treated with a degree of caution. It is conceivable that as part of their visit Palanca and Quintana would have come across incidents and attitudes they were uncomfortable with, particularly related to euthanasia policies and the atheism of the Nazi regime. It is even credible that their experiences in the occupied territories, at a time when conditions for Jews and Poles were truly terrible, would have had a profoundly negative affect on a relative moderate such as Quintana. However, these accounts follow a pattern of post-war Spanish memoirs and testimonials aimed at playing down links with the Third Reich. The majority were written by Blue Division veterans and were coloured by their desire to distance themselves from the discredited Nazi cause, whilst retaining the more positive pro-European and anti-Bolshevik character of their involvement with the Axis struggle. As Xosé Núñez Seixas has demonstrated, one way they did this was to emphasise Nazi Anti-Semitism and to make clear their opposition to it, a trope absent from contemporary accounts but increasingly prominent in the post-war era as awareness of the Holocaust grew in Spanish society.⁵⁵ Palanca's story about the Jewish doctor in Warsaw certainly fits this pattern, as does the autobiography of Pedro Laín Entralgo, who was at pains to highlight the number of times he had received disapproving looks from Germans for helping elderly Jews to cross the street.⁵⁶

There were, however, genuine ideological disagreements over Nazi attitudes towards racial hygiene, eugenics and euthanasia which affected Hispano-German cooperation in certain areas. Spanish attitudes towards race, even amongst those on the extreme right, had traditionally been based on ideas of mixture, hybridity and the fusion of peoples rather than on the idealisation of racial purity which underlay Nazi racial thought.⁵⁷ Spanish experts, both conservatives and Falangist, also took their lead from the Catholic Church in opposing ‘negative’ eugenics policies, and were much more comfortable with the idea of a ‘positive’ Latin Eugenics shared by colleagues in Italy, Portugal and Latin America.⁵⁸ This was reflected in patterns of international cooperation in the fields of population policy and racial hygiene. Demographic concerns underpinned much early Francoist public health and welfare policy, with a wide range of programmes and institutions established to support Franco's goal of reaching a population of 40 million people.⁵⁹ Whilst for Spanish experts the point of reference for population policies were the ‘totalitarian’ states which were perceived to be vigorously addressing the problem of demographic decline, they rejected the idea of active biological selection through abortion or forced sterilisation in favour of an emphasis on increasing the quantity of births and moulding the behaviour of parents.⁶⁰

As a result, Spanish interest was much more focused on the example of Italy than on the problematic policies pursued by the Nazi regime.⁶¹ Italian policies were widely disseminated through conferences, exchanges and medical journals.⁶² In September 1940 a population sciences congress in Porto brought together population experts from Spain, Portugal and Italy, including the famous Italian demographer Corrado Gini.⁶³ In 1942 the head of infant hygiene services at the Department of Health, Juan Bosch Marin, published a monograph based on a conference held at the Italian Institute of Culture entitled How Mussolini's Italy Has Resolved the Demographic Problem.⁶⁴ Progress in this field, Bosch Marín argued, was one of the finest achievements of Mussolini's government, which had been uniquely successful in addressing a problem that was besetting the whole of civilised Europe. This success he ascribed to the ‘firmness and characteristic efficiency of fascism’, which had attacked the causes of negative demographics by putting in place positive eugenic measures to stimulate population, focused on the institutions of marriage and the family and based on the ‘moral climate’ Mussolini had created.⁶⁵

Beyond these immediate fields, however, there is little evidence that ideological tensions placed any significant constraints on Hispano-German health cooperation. Communication between Spanish experts and their German colleagues was facilitated by a shared set of assumptions concerning modern public health, its role in national regeneration and the relationship between the state and sick individuals. Despite their ideological differences, for example, both regimes used the fight against infectious diseases as a means to exert political control over undesirable populations and social groups. In Nazi-occupied east-central Europe, the language, techniques and technologies of typhus control were intimately bound up with the control and destruction of Jewish populations.⁶⁶ In Spain typhus was used as a tool to exert social control and to legitimise the Franco regime, with the disease blamed on moral and material failings in the Republican zone and on ‘proletarian grime’ in Madrid.⁶⁷ In a similar way tuberculosis control was used by both governments, and by many other authoritarian regimes across Europe, as a means of controlling working-class communities and of reinforcing political discourses around race and social hygiene. In Nazi Germany the idea of the ‘malicious’ TB patient endangering the wider population by refusing treatment was used to justify forced hospitalisation, and the right of tuberculosis patients to get married was also restricted to help prevent the dissemination of their ‘inferior genotype’.⁶⁸ Anti-tuberculosis campaigns in Spain after the Civil War combined disease control with political indoctrination, focusing on changing the malignant habits of the poor.⁶⁹ These overlapping approaches to disease control meant that a set of shared assumptions underlay discussions between Spanish and German experts, who were both comfortable with the idea that, when it came to the control of infectious diseases, the needs of Volk or Raza trumped individual or civil rights.⁷⁰ When Leonardo Conti told the international tuberculosis conference that no other disease was so associated ‘with the health and the social life of . . . the State’, that public health experts were ‘generals’ in the ‘battle’ against the disease, and that the medical officials working under them were the ‘weapons with which we penetrate our sick family communities’, his language would not have appeared strange or unfamiliar to the Spanish delegates.⁷¹

Spanish experts were also able to view themselves as part of a new era of public health which encompassed the ‘totalitarian’ European states, enabling them to overlook the ideological and political differences between themselves and their German counterparts. This was facilitated by the Francoist language of ‘social medicine’, a loosely-defined concept which held that the significance of the sick individual lay in his or her relationship to the social body and to the strength and productivity of the nation, and that the state therefore needed to find a new way to manage the nation's health on a collective basis.⁷² The Spanish experts most closely involved with Nazi Germany were at the forefront of this new thinking about the state's role in health and medicine. In February 1942, shortly after returning from separate trips to Germany, both Primitivo de la Quintana and Pedro Laín Entralgo published articles on medicine and the state in a special issue of the newspaper Sí, which shed light on these shared beliefs.⁷³ The articles were remarkably similar, both recounting the history of the relationship between medicine and the state from Ancient Greece to the present day and presenting the increasingly close ties between the two as the inevitable outcome of political, social and scientific progress. Both emphasised the fact that Spanish medicine was entering a new era in which the care of the sick individual was not only valuable in and of itself but also, in the words of Quintana, ‘for the threat to the collective that he represents,’⁷⁴ what Laín called the ‘imperious necessity to attend sufficiently to the multitude’.⁷⁵ The focus on collective, state-led medical systems was not, of course, the sole preserve of the Axis states and their allies, and the practice of medicine and public health in Nazi-occupied Europe bore little resemblance to the utopian language of ‘social medicine’. Spanish experts, however, were able to maintain the idea that they formed part of common endeavour shared by what Laín referred to as ‘the totalitarian states’, united by the need to resolve the damaging legacy of the pre-war democracies and to forge a new era of medicine and public health.⁷⁶

The idea that Europe's ‘totalitarian’ states represented the future of collective health care was reflected in the research carried out for Spain's new health insurance scheme, the Compulsory Health Insurance (Seguro Obligatorio de Enfermedad; SOE), during the early years of the war. Plans for a new health insurance system, originally drawn up under the Second Republic, were revived after the Civil War by the first Francoist government, which saw social policy and social insurance as a means of legitimising the new regime, particularly amongst the working-class populations the scheme would target.⁷⁷ From the very beginning the SOE was the site of both cooperation and conflict between the regime's various factions, particularly between the Falange and figures within the Department of Health and the National Welfare Institute (Institute Nacional de Previsión; INP), which was responsible for drawing up the proposals. The INP had traditionally been dominated by sociologists and economists from Spain's centre-right and social Catholic traditions, but its position within the Ministry of Labour meant that it fell under the sway of the Falange with the appointment of the prominent Falangist Girón de Velasco as Minister in May 1941. Preparations for the new insurance scheme began in July of that year, and the planning committees consisted of a mixture of Social Catholics, technocrats and Falangists, the latter intent on ensuring the new system would fall under their control.⁷⁸

Despite these tensions, the various groups were united in looking towards the ‘New Europe’ for inspiration. In 1941 the INP published a detailed study on the social insurance schemes in the ‘totalitarian states’, focusing on Germany, Italy, Portugal and Romania, with a particular emphasis on the design of health insurance systems.⁷⁹ Social security in these states, according to the study, was fundamentally different from that developed in liberal regimes. Ignoring the extensive planning for post-war welfare reform being carried out by the Allies, it argued that the focus on collective and family welfare which lay at the heart of the ‘totalitarian theory’ of social security had ‘come to fill a void and resolve a problem which has never, until now, been solved within the framework of national legislation’.⁸⁰ The conviction that the model for Spain's welfare system came from within the ‘New Europe’ was reflected in the practical research into health insurance systems in Germany, Italy and occupied Europe which the INP organised during the war, and which involved both Falangist and conservative experts. Amongst them was Primitivo de la Quintana, who had been a member of the INP's governing body since 1939, and who was the Department of Health's representative on the SOE preparatory committee from 1941. In this role he was able to combine his Department of Health trip to Germany in 1941 with an INP study group sent to investigate the design of social security and medical insurance provision in Germany, Italy and occupied Czechoslovakia.⁸¹ This visit was followed in 1943 by a further study group sent to central Europe by the INP and led by the Falangist Secretary General of Ex-Combatants Sebastián Criado del Rey, which looked in particular at the administration of health insurance programmes, including the Sickness Fund of the German firm Siemens and welfare institutions in Prague and Budapest.⁸² This focus on ‘totalitarian’ social insurance systems lasted until the military tide had clearly turned against Nazi Germany, after which the social Catholics within the INP began to regain some control from the Falange, and the emphasis shifted to the United States and United Kingdom, in particular to the model provided by the Beveridge report.⁸³

Mutual Self-Interest and German Hegemony

Whether real or perceived, the shared visions and ideals which united Spanish and German experts were underpinned by a mutual self-interest but undermined by Germany's hegemonic position and the tensions which stemmed from it. Acting ‘internationally’ during the early years of the war provided clear practical, professional and political benefits for experts on both sides. For officials in the Spanish Department of Health, good relations with Nazi authorities were necessary to help secure vital supplies during a period of global shortages in which Germany dominated European distribution networks. José Palanca, for example, used his links with German officials to purchase pharmaceutical products on a number of occasions during the war.⁸⁴ Many Spanish experts, however, were primarily motivated by the traditional prestige of German science and medicine and by their personal experiences of studying or working there in the pre-war era. Germany had long been regarded by Spanish students and researchers as the centre of European science and medicine, and had been the preferred destination for Spanish scholarship holders across the scientific disciplines prior to the Civil War.⁸⁵ Many Spanish doctors and public health experts who cooperated with the Third Reich, including Primitivo de Quintana, had spent time studying in Germany during the 1920s and early 1930s and had maintained links with German colleagues.⁸⁶ The reputation of German science and medicine meant that some Spanish experts valued the opportunity to work with German colleagues regardless of the political circumstances.

After the outbreak of the Second World War, German diplomats exploited their traditional prestige in the fields of science and medicine as part of the wider battle with the Allies to secure the allegiance of influential Spanish elites. Both the Foreign Office and German medical and scientific associations had been working to develop bilateral ties with key European states since the end of the First World War, and had redoubled their efforts in the 1930s as Germany's international standing had been undermined by the Nazi regime.⁸⁷ Health and medicine had played an important role in the cultural agreement between Nazi Germany and the Franco regime signed in 1939, which aimed to formalise the exchange of publications and increase the number of research exchanges and medical scholarships between the two countries.⁸⁸ Wartime cooperation was facilitated by a range of organisations interested in strengthening Hispano-German relations, including the German-Iberoamerican Medical Academy and German-Spanish Society in Berlin, and the Hispano-German Association and German Cultural Institute in Madrid, all of which were supported by the German Foreign Office.⁸⁹ On a wider scale, health and welfare were an important part of the vision Germany wished to portray of the ‘New Europe’, with German propaganda emphasising the importance of improving living standards and developing social welfare systems across the continent.⁹⁰

Medical ties with Spain and the other Axis powers were also used to help meet Germany's military and economic needs during the war. The international tuberculosis conference, for example, was accompanied by a meeting between José Palanca, Leonardo Conti and the public health ministers of Italy and Hungary, in which Conti sealed agreements regarding Italian treatment of wounded and sick German soldiers and Spanish purchase of German pharmaceutical supplies.⁹¹ At the end of the following year the German government was able to use its strong relationship with the Spanish Department of Health to reach an agreement providing for Spanish doctors to work in German hospitals. As the war developed Germany had begun to face a serious shortage of doctors in civilian hospitals. Franco's government had already begun to send workers to help cover labour shortages in the Reich under the Interministerial Commission for the Dispatch of Workers to Germany (Comisión Interministerial para el Envío de Trabajadores a Alemania; CIPETA) programme, and in October 1942 the Reich Labour Ministry approached CIPETA about incorporating doctors into the scheme.⁹² At least twelve doctors left for Germany in 1943, with a further forty departing in 1944, the last in July. They represented a wide range of specialisations and were sent to work at locations across the Reich.⁹³ The Spanish Department of Health justified its agreement partly on the grounds of the professional opportunities the scheme would provide for those involved, but at a time of high mortality and morbidity rates in the aftermath of the Civil War, when the country was facing a shortage of qualified personnel following the death, persecution or exile of large parts of the Spanish medical profession, the decision clearly prioritised relations with Germany over the interests of the Spanish health system.⁹⁴ From a German perspective it could not have been achieved without the close ties already developed with leading Spanish health experts.

Germany's rapid military successes at the start of the Second World War also provided an opportunity for the German medical profession to achieve its long-held dream of replacing France as the centre of European health and medicine, something that was reflected in the prominent involvement of professional groups such as the Reich Medical Association in international health initiatives during the war.⁹⁵ At the same time, Germany's political hegemony and the obvious dominance of the German medical profession meant that the new forms of international health they attempted to create were fundamentally different from those which had existed prior to the war. Rather than creating a genuine international network, in which ideas and individuals could move in different directions between more or less equal nodes independently of the control of one group or organisation, the form of international health that developed in the early years of the war looked much more like a web, with international links radiating out from Germany but little genuine international cooperation independent of it. In the case of Spain, this was reflected in the centrality of relations with Nazi Germany, at least up until 1942. Despite their shared religious faith and Catholic-inspired distrust of Nazi eugenics, for example, Spanish medical and public health links with Italy remained more limited than those with Germany throughout the war.⁹⁶ The language and forms of pre-war international health that were used by Nazi Germany after 1939 masked a very different vision of what the ‘international’ should be, a vision in which the strict political hierarchies of the ‘New Europe’ would be reflected in the unquestioned dominance of German goals and interests.

More than the pernicious effects of Nazi occupation on health and welfare across occupied Europe or the ideological differences between the two regimes, it was this overt German hegemony and the subordinate role of Spain, both real and perceived, which caused the most tension between Spanish and German experts. Outside of the field of medicine, the poor treatment of Spanish volunteers and the perception that, although formally valued allies, they were openly treated as cultural and racial inferiors by the German authorities, was a constant complaint of the Spanish workers sent to Germany.⁹⁷ Although few similar complaints by Spanish medical professionals were made publicly at the time, and claims in later memoirs must be treated with caution, contemporary records suggest they faced similar issues. Medical officers in the Blue Division constantly complained about disrespectful treatment by German soldiers, whilst Spanish doctors working in German hospitals drew unfavourable comparisons between their treatment in Germany and their reception elsewhere in Europe.⁹⁸ Laín Entralgo later summed up the feeling shared by many Spanish experts with direct experience of the Third Reich. ‘As a southerner and Mediterranean’, he wrote, ‘I knew at the end of the day that the Nazis despised me’.⁹⁹

Conclusion

The new forms of international health which briefly emerged within Nazi-dominated wartime Europe were short-lived and ultimately unsuccessful. Regardless of whatever qualms were felt by some of the experts involved, they were unavoidably anchored in Nazi efforts to reshape Europe according to its own interests and ideology. Examining them within the wider history of twentieth century internationalism is not to suggest that this context was in any way peripheral, or that there was any ideological affinity between the liberal internationalism of the pre-war era and the Nazi New Order. What it does do, however, is highlight entanglements and parallels between the two phenomena, not least from the perspective of many of the actors involved. It also illustrates how the habits of acting and thinking ‘internationally’ that had been embedded through the growth of international organisations and networks prior to the war served to underpin support for the idea of a reformed and reformulated international system under Nazi leadership.

The ease with which experts moved between both forms of international health stemmed in part from the flexible way in which the field of public health could be conceived as both a ‘technical’ and a ‘political’ form of international cooperation. Since the nineteenth century experts had presented international health as a purely scientific and technical endeavour in which international cooperation was a necessary response to the an increasingly globalised world in which diseases passed easily over national borders and health conditions in one country were so obviously dependent on those of its neighbours. At the same time many public health experts, particularly on the left, saw international health as a politically progressive force, helping to spread social values and practices across borders.¹⁰⁰ This same flexibility enabled European experts to justify their work with Nazi Germany on either scientific or political grounds. As Leonardo Conti made clear in his speech to the tuberculosis conference in Berlin, international cooperation was particularly important in times of war because of the epidemiological risks posed by the mass movement of people, an argument which could appeal to those experts who saw their work with Nazi authorities as purely ‘technical’. On the other hand, Spanish experts in part looked towards Nazi Germany and Fascist Italy because of the perception that they formed the vanguard of a new ‘totalitarian’ form of public health, with which Spain shared an ideological affinity. European experts keen to maintain their international status during the war could draw on a wide range of arguments to justify their involvement with Nazi Germany.

Rather than representing a brief authoritarian interlude in the progressive history of international health in the twentieth century, destined to fail and rightfully forgotten, this ‘Axis internationalism’ highlights the flexibility of a particular group of experts willing to adapt to a new vision of public health and to a new political reality within the Nazi ‘New Europe’ during the first half of the war. Many of those who cooperated willingly but unenthusiastically with Nazi Germany in 1941 in order to further their professional and national interests had adopted a similar approach to the LNHO in the 1930 and would do the same again with the WHO in the 1950s. More significant than the relatively limited number of pro-Nazi collaborators, these experts formed part of a much wider group of elites from across the European right, who, in the words of Walter Lipgens, ‘approved of Nazi doctrines in some though not all respects and, in view of what seemed the finality of Hitler's rule over the continent, were prepared to collaborate sincerely with the Nazis in order to ensure for their own nation a position of importance in the “New Order”’.¹⁰¹